Persistent Postural-Perceptual Dizziness

Persistent Postural-Perceptual Dizziness (PPPD) is a condition that causes ongoing dizziness, unsteadiness or non-spinning vertigo that lasts for three months or more. Symptoms are typically worse when standing or walking, when moving your head or body, and in visually busy environments such as supermarkets or crowded places.

PPPD is classed as a chronic functional vestibular disorder. The inner ear and brain structures are usually intact, but the way the brain processes balance, motion and visual information has become over-sensitive and “stuck” in a heightened state.

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What Is Persistent Postural-Perceptual Dizziness?

PPPD was formally defined in 2017 by the Bárány Society, the international body that classifies vestibular disorders. According to the diagnostic criteria, PPPD:

• Causes dizziness, unsteadiness or non-spinning vertigo on most days for at least three months
• Symptoms are usually worse in an upright position (standing or walking)
• Symptoms increase with active or passive movement (moving your head or body, travelling in a vehicle)
• Symptoms are exacerbated by complex or moving visual patterns, such as supermarket aisles, screens or traffic
• Typically develop after a “trigger event”, such as an acute vestibular episode (e.g. BPPV, vestibular neuritis, Ménière’s disease), a migraine, panic attack, concussion, or another medical illness

PPPD is sometimes described as a “software” rather than “hardware” problem: routine scans and balance tests may be normal, but the brain has shifted into a persistent pattern of hypervigilance and over-reliance on visual information, making you feel off-balance and uneasy.

The symptoms are real, involuntary and often disabling, but they are potentially reversible with the right explanation and rehabilitation.

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Causes and Triggers

PPPD almost always begins after a trigger event that upsets the balance system. Common triggers include:

• An episode of acute vertigo, such as:
  • Benign paroxysmal positional vertigo (BPPV)
  • Vestibular neuritis or labyrinthitis
  • Ménière’s disease or other inner ear disorders
• Vestibular migraine or other migraine attacks
• Concussion or mild traumatic brain injury
• Panic attacks or severe anxiety episodes with dizziness
• Other acute medical problems (e.g. fainting episodes, significant illness or injury)

In most people, the acute episode settles, but the brain remains in a “high alert” state for balance and motion. This can lead to:

• Increased reliance on vision for balance
• Heightened awareness of bodily sensations (watching closely for dizziness)
• Avoidance of movement and busy environments, which can de-condition the balance system
• Anxiety and worry about dizziness, falls or serious illness

Over time, these changes can lock in a pattern of persistent dizziness and unsteadiness – even though the original trigger has resolved.

Psychological factors such as anxiety, low mood, health worry or previous trauma do not mean the symptoms are imaginary, but they can increase vulnerability to PPPD and maintain symptoms once they have developed.

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Symptoms of PPPD

Symptoms can vary in intensity but follow a consistent pattern. People with PPPD often describe:

• Persistent dizziness or unsteadiness – feeling “off-balance”, “on a boat”, “floating” or “rocking” rather than spinning
• Symptoms present on most days for at least three months, often waxing and waning within the day
• Worse when upright – standing, walking or standing still in queues
• Worsening with movement – head turns, bending over, quick position changes, travelling in a car, bus or train
• Increased discomfort in visually busy environments, such as supermarkets, shopping centres, crowds, escalators, scrolling on screens or driving in heavy traffic
• Feeling mentally drained or “foggy” alongside dizziness
• Heightened anxiety or fear of falling, particularly in open spaces or crowded places

Associated symptoms can include:

• Neck or shoulder tension
• Headache or migraine
• Sensitivity to light and noise
• Nausea or motion sickness
• Fatigue and reduced activity levels

Symptoms may lessen when lying down or sitting still, but they rarely disappear completely without treatment.

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How PPPD Is Diagnosed

There is no single test for PPPD. Diagnosis is based on a specialist assessment using the Bárány Society criteria, usually by an ENT, neurology or vestibular specialist, sometimes with neuro-otology or neurophysiology input.

Assessment typically includes:

• Detailed history of dizziness – onset, triggers, time course and impact on daily life
• Questions about previous vestibular problems, migraine, concussion, anxiety or panic
• Physical examination and, if appropriate, vestibular tests (such as head-impulse test, positional testing, caloric tests, VNG)
• Hearing tests and sometimes imaging (MRI) to rule out other causes
• Consideration of psychological factors, such as health worry or agoraphobia

PPPD is diagnosed when:

• Dizziness/unsteadiness has been present on most days for ≥3 months
• Symptoms are worse with upright posture, movement and complex visual stimuli
• Another condition may have triggered the onset but no longer fully explains the ongoing symptoms
• No alternative diagnosis (such as ongoing acute vestibular disorder, stroke or structural brain disease) better accounts for the presentation Vestibular Disorders Association+3PubMed Central+3PubMed+3

An accurate diagnosis – and clear explanation that PPPD is real but usually treatable – is often the first key step in recovery.

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Treatment and Management

There is no “quick-fix tablet” for PPPD, but research shows that a multimodal approach can significantly reduce symptoms and improve quality of life. This usually combines vestibular rehabilitation, psychological strategies and, in some cases, medication.

1. Education and Re-assurance

• Clear explanation that PPPD is a functional vestibular disorder, not a sign of ongoing damage
• Discussion of how the brain has become over-sensitive and hypervigilant to motion and visual information
• Involving family or carers so they understand why gradual activity is encouraged, not over-protection

2. Vestibular Rehabilitation Therapy (VRT)

Vestibular physiotherapy is a core part of PPPD management. It focuses on:

• Graded exercises to retrain balance and head-eye coordination
• Controlled exposure to movement and visually complex environments, rather than avoidance
• Improving confidence in standing, walking and everyday tasks
• Addressing posture, neck tension and general fitness

Evidence suggests that structured VRT can reduce dizziness handicap and improve function, particularly when started earlier in the course of PPPD.

3. Psychological Therapies

Psychological support does not imply that dizziness is “all in the mind”. Instead, it addresses how attention, thoughts and emotions influence the balance system.

Approaches may include:

• Cognitive Behavioural Therapy (CBT) to:
  • Reduce fear of dizziness, falls and “catastrophic” beliefs about symptoms
  • Decrease safety behaviours and avoidance, which can maintain PPPD
  • Shift focus away from constant self-monitoring towards external tasks
• Strategies for managing panic, anxiety and hypervigilance
• Support for adjustment, mood and quality of life

Studies show that CBT, especially when combined with VRT, can further reduce dizziness impact and disability.

4. Medication

There is emerging evidence that selective serotonin reuptake inhibitors (SSRIs) and sometimes other antidepressants can help reduce PPPD symptoms in some people, particularly when anxiety is prominent.

• Medication is usually prescribed and monitored by a GP, psychiatrist or specialist
• It is typically used alongside, not instead of, rehabilitation and psychological strategies
• Any decision about medication should be individualised, balancing potential benefits and side-effects

5. Lifestyle and Self-Management

• Gradual return to activity, avoiding prolonged rest and complete avoidance of triggers
• Regular, paced aerobic exercise, as tolerated
• Sleep, hydration and routine support
• Limiting alcohol and substances that may worsen dizziness
• Using relaxation, breathing and grounding techniques to manage anxiety in triggering environments

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PPPD, Vestibular Disorders and Functional Neurological Disorder (FND)

PPPD sits at the intersection of vestibular disorders, anxiety and FND-style functional symptoms:

• Many people develop PPPD after a clear vestibular event (e.g. BPPV, vestibular neuritis or migraine), but the original problem resolves while dizziness persists in a functional pattern.
• PPPD can coexist with Functional Neurological Disorder (FND), such as functional gait disorder, functional limb weakness or dissociative (non-epileptic) seizures.
• PPPD is sometimes considered a functional vestibular phenotype, and the principles of FND rehabilitation – retraining automatic control rather than “strength” alone – are highly relevant.

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How We Can Help at The Royal Buckinghamshire Hospital

We support adults with PPPD whose dizziness and balance problems significantly affect independence, mobility and quality of life, particularly where there are complex neurological, FND or psychological factors.

Our consultant-led inpatient neurorehabilitation programmes may include:

• Neurophysiotherapy / vestibular rehabilitation
  • Individualised VRT programmes
  • Gait, balance and confidence training
  • Graded exposure to movement and visually challenging environments
• Occupational therapy
  • Practical strategies for daily activities that trigger dizziness
  • Pacing and energy management
  • Support for return to work, driving and community activities
• Clinical psychology / neuropsychology
  • Education about PPPD and functional vestibular disorders
  • CBT-informed work on anxiety, hypervigilance and avoidance
  • Support with mood, adjustment and self-management
• Medical oversight
  • Review of previous investigations and diagnoses
  • Optimisation of medication where appropriate
  • Coordination with referring ENT, neurology or vestibular services

Programmes are goal-focused and time-limited, with planning for ongoing community-based rehabilitation or outpatient therapies where needed.

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When to Seek Urgent Medical Help

This page provides general information and is not a substitute for emergency care or individual medical advice.

You should seek urgent medical help (999 / emergency department) if you experience:

• Sudden, severe dizziness or vertigo with:
  • New weakness, numbness or difficulty speaking
  • Sudden loss of vision or double vision
  • Sudden severe headache unlike anything before
  • Chest pain, breathlessness or collapse

These symptoms may indicate stroke, cardiac or other serious conditions and must be assessed immediately.